Implementing Mailed Colorectal Cancer Fecal Screening Tests in Real-World Primary Care Settings: Promising Implementation Practices and Opportunities for Improvement

• Authors: Sarah D Hohl, University of Washington; Annette E Maxwell, University of California Los Angeles; Krishna P Sharma, Totally Joined Achieving Collaborat Tech; Juzhong Sun, Totally Joined Achieving Collaborat Tech; Thuy T Vu, University of Washington; Amy DeGroff, National Center for Chronic Disease Prevention and Health Promotion, CDC, Atlanta; Ngoc-Cam Escoffery, Emory University; Dara Schlueter, National Center for Chronic Disease Prevention and Health Promotion, CDC, Atlanta; Peggy A Hannon, University of Washington
• Journal Title: PREVENTION SCIENCE
• Publisher: SPRINGER/PLENUM PUBLISHERS | 2023-03-23, Pages 1-12
• Type of Work: Article | Final Publisher PDF
• Publisher DOI: http://doi.org/10.1007/s11121-023-01496-3
• Subjects: Health Sciences, Medicine and Surgery; Health Sciences, Oncology
• Keywords: Science & Technology; Life Sciences & Biomedicine; Public, Environmental & Occupational Health; Mailed fecal testing implementation; Evidence-based interventions (EBIs); Colorectal cancer (CRC) screening; Safety-net clinics; Fecal immunochemical testing; Fecal occult blood test; Mailed outreach; Colorectal neoplasms; COLONOSCOPY; INTERVENTIONS; OUTREACH

Abstract

Colorectal cancer (CRC) screening reduces morbidity and mortality, but screening rates in the USA remain suboptimal. The Colorectal Cancer Control Program (CRCCP) was established in 2009 to increase screening among groups disproportionately affected. The CRCCP utilizes implementation science to support health system change as a strategy to reduce disparities in CRC screening by directing resources to primary care clinics to implement evidence-based interventions (EBIs) proven to increase CRC screening. As COVID-19 continues to impede in-person healthcare visits and compel the unpredictable redirection of clinic priorities, understanding clinics’ adoption and implementation of EBIs into routine care is crucial. Mailed fecal testing is an evidence-based screening approach that offers an alternative to in-person screening tests and represents a promising approach to reduce CRC screening disparities. However, little is known about how mailed fecal testing is implemented in real-world settings. In this retrospective, cross-sectional analysis, we assessed practices around mailed fecal testing implementation in 185 clinics across 62 US health systems. We sought to (1) determine whether clinics that do and do not implement mailed fecal testing differ with respect to characteristics (e.g., type, location, and proportion of uninsured patients) and (2) identify implementation practices among clinics that offer mailed fecal testing. Our findings revealed that over half (58%) of clinics implemented mailed fecal testing. These clinics were more likely to have a CRC screening policy than clinics that did not implement mailed fecal testing (p = 0.007) and to serve a larger patient population (p = 0.004), but less likely to have a large proportion of uninsured patients (p = 0.01). Clinics that implemented mailed fecal testing offered it in combination with EBIs, including patient reminders (92%), provider reminders (94%), and other activities to reduce structural barriers (95%). However, fewer clinics reported having the leadership support (58%) or funding stability (29%) to sustain mailed fecal testing. Mailed fecal testing was widely implemented alongside other EBIs in primary care clinics participating in the CRCCP, but multiple opportunities for enhancing its implementation exist. These include increasing the proportion of community health centers/federally qualified health centers offering mailed screening; increasing the proportion that provide pre-paid return mail supplies with the screening kit; increasing the proportion of clinics monitoring both screening kit distribution and return; ensuring patients with abnormal tests can obtain colonoscopy; and increasing sustainability planning and support.